Severe Cholestasis from Bodybuilding Supplements: The Dangers of Product Contamination

ABSTRACT

Background: Drug-induced liver injury (DILI) is the leading cause of acute liver injury in Western countries. Herbal and dietary supplements are the second most common cause of idiosyncratic DILI. In this case study, a young male with history of hepatitis C infection with sustained viral response presented with acute liver injury. Method(s) Liver function tests were performed as below. CT scanning were reviewed by a radiologist. Liver biopsy was done with routine H&E staining and reviewed by a pathologist. Result(s) Our patient presented to an outpatient clinic with muscle cramping fatigue, and diffuse itching. He previously had icteric sclera, dark urine, and abdominal pain a month prior that resolved after a few weeks. Patient denied any recreational drug use in the past year and rarely drank alcohol. Patient was using protein shakes and, pre- and post-workout supplements he bought at GNC. His labs were notable for a total bilirubin was 2.8 mg/dL, aspartate aminotransferase (AST) was 76 U/L, alanine aminotransferase (ALT) 191 U/L and the level of alkaline phosphatase 103 U/L. INR was 0.9. Creatinine kinase level was 320 U/L. Acute hepatitis A, B, and C were negative. The following next ten days, he pruritis worsened and he reported a progressive rash in his trunk and extremities. HIV, TSH, EBV, CMV, and COVID-19 testing were also negative. Repeat labs revealed creatinine kinase level normalized. The total bilirubin had increased from 5.3 mg/dL to 8.2 mg/dL, including a direct bilirubin of 6.6 mg/dL. AST and ALT had decreased, and INR remained normal. CT scan of his abdomen did not show cholecystitis or choledocholithiasis. Live biopsy showed bland cholestasis and sinusoidal dilation (fig 1). Patient ultimately required plasmapheresis and diagnosis of anabolic-androgenic steroid-induced liver injury was made. Conclusion(s) This case highlights an important complication of OTC use spiked with unexpected substances. Anabolic-androgenic steroidinduced DILI is characterized by cholestatic liver injury pattern with bland cholestasis on liver biopsy. In this case, patient's presentation was pathognomonic for anabolic-androgenic steroid-induced DILI despite only using OTC workout supplements. As supplement use in the United States increases, product contamination may place patients at an increasing risk for DILI. It is crucial to report suspected cases of hepatotoxicity and advocate for regulatory change to improve the health and safety of athletes.